Information Collection

Certification of Funeral Expenses

IC 13646 under ICR 201409-1240-010 · OMB 1240-0040.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1240-0040 can be found here:

Documents and Forms

Document Name Document Type
Form LS-265 Certification of Funeral Expenses Form
LS-265 Certification of Funeral Expenses ls-265.pdf www.dol.gov/owcp/dlhwc/ls-265.pdf Form
DLHWC Seaportal.pdf DLHWC SEA Portal IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Certification of Funeral Expenses	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 702.121

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	LS-265	Certification of Funeral Expenses	ls-265.pdf	http://www.dol.gov/owcp/dlhwc/ls-265.pdf	Yes	No	Fillable Printable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title: DOL/GOVT-15	FR Citation: 67 FR 16870

Number of Respondents: 75	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	75	75
Annual IC Time Burden (Hours)	19	19
Annual IC Cost Burden (Dollars)	39	39

Documents for IC

Title	Document	Date Uploaded
DLHWC SEA Portal	DLHWC Seaportal.pdf	09/24/2014

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.